Study Finds Bias in Way Women Are Evaluated for Heart Bypasses

By GINA KOLATA

Published: April 16, 1990

Women who have bypass surgery for heart disease are much sicker and slightly older than men who have the surgery, researchers said yesterday, adding that the finding could explain why those women were more likely to die as a result.

The study, published yesterday in The Annals of Internal Medicine, found a bias against referring women for bypass surgery, said Dr. Steven S. Kahn, who conducted the research with colleagues at the Cedars-Sinai Medical Center in Los Angeles. ''For women's symptoms to be acted on, they have to be significantly sicker,'' he said. ''They have to prove there is something going on.''

Dr. Claude Lenfant, director of the National Heart, Lung and Blood Institute in Bethesda, Md., said that if the researchers' findings are correct, ''it will add to the concern that is voiced in many circles'' that although heart disease is a serious problem for women, it is not taken seriously enough by researchers or doctors. He said he had not seen the study.

Putting It Off Too Long

Dr. Nanette K. Wenger, a cardiologist who is a professor at the Emory University School of Medicine in Atlanta, said bypass surgery ''should be done on an elective basis in women, as it is in men.''

''When women come in,'' she went on, ''they are in such critical condition that the operations have to be done on an emergency basis. Obviously, there will be a less favorable outcome.'' Dr. Wenger wrote an editorial to accompany Dr. Kahn's article.

Other experts said they doubted that there was a bias against referring women for bypass surgery and suggested that the women might have taken medications that concealed the symptoms until they were very ill, or might not have described their symptoms as men do, using words that might alert the doctor.

In bypass surgery, a vein is taken from a leg or an artery is taken from the chest to create a route around a blocked coronary artery, relieving chest pain that often accompanies heart disease. Heart disease is the leading cause of death in men, starting with 40-year-olds, and it is the leading cause of death in women from 60 on.

Mortality Rates Compared

The study examined clinical data on 2,297 consecutive patients who had bypass surgery at Cedars-Sinai. It found that the women were much more likely to die while they were still in the hospital, and were much sicker and slightly older than the men. Their mortality rate was 4.6 percent as against 2.6 percent for the men. The average age of the women was 68, that of the men 62.

Many of the women undertook the surgery because they had had a heart attack or other sign of heart disease, like congestive heart failure. Many of the men had had an exercise stress test whose results were abnormal, but no other symptoms of heart disease.

The researchers concluded that the difference in mortality was entirely explained by the women's being sicker and older.

Difficulties With Women

Dr. Kahn said many cardiologists believed that women are poorer candidates for bypass surgery because they are smaller than men and their hearts are more difficult to operate on. He argued that his findings disputed that thesis.

Dr. Wenger said previous studies had indicated that doctors were less likely to heed women's complaints of chest pains than men's. In one study, only 4 percent of the women whose heartbeats became abnormal in exercise stress tests were sent to get angiograms, which provide pictures of blockages in coronary arteries. But 40 percent of men with abnormal heartbeats were directed to get angiograms.

The new study ''highlights current clinical practice,'' Dr. Wenger said, adding: ''It says, 'Look, doctor, you're behaving differently when you order the same test for men and for women.' It says: 'Look, doctor, when a woman tells you there's a lot of coronary disase in her family, you're being pushed. Take it seriously.' ''

She added that she hoped the findings would ''raise the consciousnesss of cardiologists.''

Cardiology as Intervention

But Dr. Harriet P. Dustan, a former president of the American Heart Association who is a cardiologist at the Veterans Administration Medical Center in Birmingham, Ala., said she did not think cardiologists treated women differently.

''Most cardiologists are interventionists,'' Dr. Dustan said. ''They welcome the opportunity to do something for people.'' She said many women might be taking medications for heart disease that mask symptoms until they are very ill and need an emergency bypass.

And Dr. Thomas J. Ryan, chief of cardiology and professor of medicine at the Boston University School of Medicine, said: ''I really don't think there's a referral bias. I think once a woman is identified as having symptomatic coronary disease, there is the same knee-jerk reflex to bring her to intervention as there is for a male.'' The problem, Dr. Ryan said, ''is being convinced of the diagnosis on clinical grounds'' when the patient is a woman.

He said women with heart disease often have atypical symptoms or describe them differently from men, throwing doctors off the track. He said this difference in reported symptoms ''may well be due to differences in communication techniques'' between men and women. But he added, ''I don't think there's any cultural disbelieving of women's symptoms.''

Dr. Ryan said the hypothesis that male doctors were disregarding women's complaints of heart disease was ''highly unlikely and reflects feminist paranoia.''